Critics Say Insurance Companies Deny Medical Claims to Make Billions in Profit

In what advocates call a “grotesque display of corporate profiteering,” the health insurance giant formerly known as Anthem reported making $2.3 billion in net profit off its policyholders over the past three months as analysts predict a dramatic spikeIn 2023, the cost of insurance premiums for health care.

On Wednesday, Elevance Health, which is the largest for-profit company in the Blue Cross Blue Shield Association, exceeded Wall Street expectations. reportedThe third quarter of 2022 saw a record revenue of nearly $40 billion. The return to shareholders increased by 7 per cent, generating approximately $40 billion in revenue. $1.6 billion in profitsFor investors. Elevance provides insurance for health. 118 millionPeople from many states.

Elevance claims its profits come from providing more service to customers. But, Elevance’s profits are attributed to health care activists who assist patients in fighting for insurance coverage. They claim that a large portion of this profit comes from denial of insurance claims from people who cannot afford it. Denying claims, they say, is a “regular business practice” for squeezing out extra profits. Insurers know that the majority of patients don’t exercise their right to appeal denied claims and are often unsure how to do this.

“Part of this money is made denying claims,” said Aija Nemer-Aanerud, Health Care For All campaign director at People’s Action, in an interview. “How many surgeries, medications and doctor visits would $2.3 billion amount to if we didn’t live under a for-profit system set up to advance the interests of greedy corporations instead of actually care for people?”

Elevance’s spokesperson did not respond to an email asking for internal data. This would have shown whether the company is turning profit by denial of claims. However, organizers have collected some information. horror storiesFrom patients across the country. The six largest private insurance companies in private health care made $41 billion in 2021. In 2020, private insurers denied more patients than they had approved. 42 million in-network claims from patients covered by Affordable Care Act (ACA) marketplace plans, according to People’s Action and the Kaiser Family Foundation.

We know that almost because of the federal transparency requirements related to ACA subsidies. one in fiveIn 2020, private insurers denied claims under ACA Marketplace plans. This does not include the private plans that are offered by employers to ACA plan participants. Eleana Molise of ONE Northside in Chicago stated that one in seven medical claims will be denied in the United States.

“This especially affects Black and Brown people who are sold the worst insurance, and people in rural America, where you get fewer or no health care providers, or they are ‘out-of-network,’ meaning you get stuck with the bill,” Molise said in a livestream Tuesday with health care advocates, impacted patients and Sen. Bernie Sanders (I-Vermont).

“A rational health care system is a system that guarantees health care for all as a human right, and it is s system that is cost effective, a system that is comprehensive … it is not a system designed to make private health insurance companies huge profits,” Sanders said, repeating his call for universal public health insurance known as Medicare for All.

Private health insurers will often refuse to pay for medical care under the rules baked into insurance plans — deductibles must be met, doctors must be within the insurer’s network, and any drugs prescribed must be on the insurer’s approved list of medications.

Advocates report that many people are left with huge medical bills that are not covered by their plans. This can lead to them having to pay out-of pocket or challenging the insurer through frustrating appeals processes.

“The wolf is guarding the henhouse,” said Ken Whittaker, executive director of the social justice group Michigan United. “They know most people don’t know you can appeal your claim, and less than 1 percent appeal claims when they are denied … and that’s more money for CEOs and Wall Street investors.”

While it’s unclear just how much profit is raised by denying insurance claims, advocates say the industry’s behavior leaves little doubt that private insurers are gouging patients and public health care programs. In 2020, Elevance CEO John Dewey took home $17 Million in salary and bonuses. This was the same year Elevance Blue Cross Blue Shield companies agreed not to pay a monetary penalty. $2.67 billion settlementIn a major antitrust case brought on behalf of policyholders.

Recent New York Times investigationPrivate insurance companies profited from Medicare Advantage, which provides private healthcare coverage for people aged 65 and over but is paid for by federal government. This allowed them to make billions of dollars from taxpayers. Elevance and other large insurers sent the government inflated bills. Federal lawsuits are pending against Elevance and others for their elaborate schemes to inflate profit. As The Times notes:

Anthem, a large insurance company now called Elevance Health paid more to doctors who claimed that their patients were more sick. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again.

Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.

After an insurance company refuses to pay medical bills, an emergency room visit or a major illness are the most common form of claim denial, Nemer-Aanerud said, but millions of uninsured and underinsured people are unable to afford basic preventative care that would help them stay healthy long-term — and keep costs down for everyone else. Insurers also deny coverage of prescriptions and lifesaving treatment. This is often due in part to secret kickback agreements with pharmaceutical companies. These agreements drive up drug prices, and determine which medications are covered.

Callie Gibson, the wife of Mark Hall, was denied proper medication due to a chronic digestive condition. She said that it is affecting her family now, but that any one can be denied health coverage. Hall was on medication that worked for years, but after switching from Medicaid to a private employer’s plan through Cigna Health, he was forced to switch to a biosimilar despite an appeal from his doctor. Hall is unable to live his normal life due to the fact that the new drug does insufficiently control his stomach bleeding and other painful symptoms.

“Because ultimately, the insurance companies don’t care about you as an individual,” Gibson said during the livestream with Sanders, reflecting on the couple’s experience with Cigna. “They care about their shareholders, the people who are making money off this company, and they are not going to take action as long as they are continue to make money, and until we hold them accountable for what they are doing.”

The Health Care For All campaign helps people fight for their claims through appeals. Anyone who has been denied coverage is encouraged to participate in the campaign. contact the campaign.